Provider Demographics
NPI:1871242362
Name:BALES, ERIC RAYMOND (ATC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:RAYMOND
Last Name:BALES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 FEDERAL PL
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2046
Mailing Address - Country:US
Mailing Address - Phone:765-490-8144
Mailing Address - Fax:
Practice Address - Street 1:175 N TORNADO DIVISION RD BLDG 2866
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-4218
Practice Address - Country:US
Practice Address - Phone:502-624-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0032982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer